Co-occurring DisordersSubstance Abuse and Trauma

The term “co-occurring disorder” refers to the abuse/dependence of substance use and mental disorders.

Co-occurring disorders are so common with trauma survivors that they should be considered expected rather than an exception. They are associated with a variety of negative outcomes, including high relapse rates, hospitalization, violence, incarceration, homelessness and serious infectious diseases (CODI, 2004).

It is currently estimated that one in five Canadians will experience a mental illness in their lifetime. The remaining four will have a friend, family member or colleague who experiences mental illness.

About 20% of people with a mental disorder have a co-occurring substance use problem. One in 10 Canadians aged 15 and over report symptoms consistent with alcohol or illicit drug dependence.

Only one-third of those who need mental health services In Canada will actually receive them (Centre for Addiction and Mental Health, 2012).

Persons diagnosed with co-occurring disorders have one or more mental disorders, as well as one or more disorders relating to alcohol or substance abuse.

People with a lifetime history of PTSD have elevated rates of co-occurring disorders. Among men with PTSD, the highest rates are for co-occurring alcohol abuse or dependence. Research also shows that PTSD is a risk factor for substance abuse and addiction.

Substance abuse is very common amongst individuals who have experienced trauma because it is a quick way to numb feelings and avoid their profound emotional pain and suffering. When an addiction is present, assessment should consider any existing traumatic impacts.

In mental health programs, it is estimated that 25 to 50% of people have a substance use disorder. This is mirrored in drug treatment facilities where it is estimated that 50 to 75% of people have a mental disorder. The two issues cannot be separated because they are so closely interwoven. If the person was not dealing with trauma, they would not feel the need to use substances to cope. One issue triggers the other. For example, sobriety often reveals unresolved memories and emotional pain that can flood the addicted individual who then uses substances, alcohol and addicting behaviours to regulate and numb their emotions.

Many mental illnesses are born out of unresolved trauma from childhood. For many people, disorders such as depression, personality disorders, and anxiety disorders are directly related to a history of unresolved trauma. What can often happen is treatment addresses only the current symptoms of the “disorder” and not the root cause. According to Judith Herman, “Survivors of childhood abuse, like other traumatized people, are frequently misdiagnosed and mistreated in the mental health system. Because of the number and complexity of their symptoms, their treatment is often fragmented and incomplete” (Herman, 1992).

This demonstrates the strong link between trauma, mental illness, and substance abuse. If and/or when the root cause is not addressed, people use substances to manage the pain and push down the memories and negative feelings associated with the trauma. This becomes a negative cycle that keeps the person stuck until both the trauma and the substance abuse issues are treated. There can also be a tremendous amount of shame associated with substance use, and not being able to quit is then layered upon the shame the individual may experience in association with the original trauma.

These issues can and should be treated at the same time so the individual who experienced the trauma doesn’t work on one issue while the other is being neglected. The source of the psychological pain must be addressed to positively impact reduction of substance use. When this doesn’t happen, people who have experienced trauma often fall through the cracks of the social service and health systems and receive poor care.

The attitude of “you must get clean before you can work on your trauma issues” keeps them stuck. Dr. Wendi Woo’s (2012) review of patient histories at Homewood in Guelph, Ontario, points out that trauma issues are not resolved through sobriety alone. Skills in emotional regulation and coming to terms with past traumas are necessary to lessen their impact. Lisa Najavits (2002) developed a series of modules that address the combined challenges found in both addiction and trauma, and then designed interventions that help clients gain mastery over relapse, social isolation, underlying anxiety, and emotional volatility.

Similar interventions that focus on developing awareness, selfsoothing practices, and non-udgmental appraisal of thoughts and emotions are also helpful. Mindfulness Based Relapse Prevention, a group model piloted by G. A. Marlatt, and Marsha Linehan’s Dialectical Behavioural Therapy, can be helpful in both addictions and trauma. These therapies teach clients to directly address the troubling symptoms that lead to further negative ways of coping (Bowen & Vieten, 2012; Hayes & Levin, 2012).

It is important to let people affected by trauma know that it’s normal to use substances to cope with the overwhelming emotions, and that help exists for reducing or stopping substance use and for addressing the traumatic issues.

CODI

The Co-occurring Mental Health and Substance Use Disorders Initiative of Manitoba (CODI) was undertaken as a partnership project of the Winnipeg Regional Health Authority, the Addictions Foundation of Manitoba, and Manitoba Health. For further information, see the WRHA website.

It’s like I can live without fear of being harmed again. Sometimes I still feel scared, but I know that I am stronger now and I’m a better person for having gone through it. I feel like my recovery is well on its way now.
Trauma survivor